<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409813
Report Date: 05/28/2025
Date Signed: 05/28/2025 10:54:40 AM

Document Has Been Signed on 05/28/2025 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:VALDIVIESO, ANAFACILITY NUMBER:
073409813
ADMINISTRATOR/
DIRECTOR:		ANA VALDIVIESOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 499-3521
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/28/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:ANA VALDIVIESOTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 28, 2025, Licensing Program Analyst (LPA) Tasha Alexander met with applicant Ana Valdivieso for the purpose of conducting an ANNOUNCED PRE-LICENSING inspection. Living in the home is the applicant,her fingerprint cleared and TB tested adult son Cesar Silva. Present in the home for today’s inspection was the applicant, and her son. The hours of operation will be Monday - Friday, 7:00 AM to 5:30PM. Age range 3 months to 9 years old.

he facility is a 3 bedroom, 2 bathroom home rented by the applicant and contains a living room, dining room, kitchen, three bedrooms (1 master with an attached bathroom), garage, and a rear yard off the dining room. The home is neat and clean with heating and ventilation for safety and comfort. Per the applicant, the ISOLATION AREA will be in the on-limits 3rd bedroom (nap room) away from the other children in care, until the parents pick up.

On-limit-areas include: Living room, dining room, hall bathroom, kitchen and backyard. Applicant was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area.

Off-limit-areas include: Two of the bedrooms in the home, which are the master bedroom and bathroom, and son's bedroom, and garage. The off-limit areas will be inaccessible by closed and/or locked doors, child gates and/or by adult supervision.

Applicant does not have liability insurance and will have parents sign the notice of no liability insurance and keep the document in the children’s files. Ratios were discussed and a copy left for applicant as a reminder. Per applicant, there are no firearms in the home.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Tasha Hackett-Alexander
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: VALDIVIESO, ANA
FACILITY NUMBER: 073409813
VISIT DATE: 05/28/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The home has a working smoke detector, working carbon monoxide detector, telephone (cell phone), first aid kit, and a fully charged 3A40BC fire extinguisher which meets standards established by the State Fire Marshal.

. The applicant completed and received a certificate in mandated reporter training on 12/16/2023. Licensee's CPR and First Aid certificate is current and expires 04/25/2027. Outdoor play will be in the backyard.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA discussed the safe sleep regulations with applicant, and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant, of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment

The applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Tasha Hackett-Alexander
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: VALDIVIESO, ANA
FACILITY NUMBER: 073409813
VISIT DATE: 05/28/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The applicant was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.




A copy of the rental agreement was reviewed and shows control of property. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC9149).

On 04/30/2025, the California Attorney General- Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure: therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ

CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Tasha Hackett-Alexander
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: VALDIVIESO, ANA
FACILITY NUMBER: 073409813
VISIT DATE: 05/28/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Roster of the children must be properly maintained and fire/disaster drill every six months must be documented. The applicant is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Applicant reminded to have the parent board with required documents at the entry of the home and/or where the parent enter.

Entrance Checklist was provided to the applicant.

Exit interview conducted and report was reviewed with the applicant, Ana Valdivieso. Appeal rights provided. This home is recommended for Licensure on May 28, 2025.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Tasha Hackett-Alexander
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5